Terms and Exclusions Clause Samples

Terms and Exclusions. I understand that the Membership Fee payable to HIM strictly covers healthcare, amenities and service that are not reimbursed or covered through the Medicare, Medicaid and third-party payers (health insurance) programs. As such, HIM will not seek reimbursement for services provided as part of your Membership Fees with your medical insurance. I understand that I am solely financially responsible for payment of my Membership Fees and that this fee is not reimbursable by my private insurance carrier, Medicare or Medicaid. However, some of the fees for my membership fee may be submitted to my health savings account (HSA), medical savings account (MSA) or flexible benefits account (FBA) for reimbursement but please consult a tax expert or your tax preparer for guidance in this regard.

Terms and Exclusions. I understand that the Membership Fee payable to HIM strictly covers healthcare, amenities and service that are not reimbursed or covered through the Medicare, Medicaid and third-party payers (health insurance) programs. As such, HIM will not seek reimbursement for services provided as part of your Membership Fees with your medical insurance. I understand that I am solely financially responsible for payment of my Membership Fees and that this fee is not reimbursable by my private insurance carrier, Medicare or Medicaid. However, some of the fees for my membership fee may be submitted to my health savings account (HSA), medical savings account (MSA) or flexible benefits account (FBA) for reimbursement but please consult a tax expert or your tax preparer for guidance in this regard. Patient History Form Name: Birth date: Marital Status: Occupation: Allergies to Medications, Latex or Dyes □None □ Yes (please list) Surgeries/Hospitalizations/Serious Injuries Year Hepatitis B Series Recent Pneumonia Vaccine Gardasil Series Recent Flu Vaccine Chicken Pox immunization or disease Positive TB Screening Health Maintenance No Yes (Year) No Yes (Year) Colonoscopy Bone Density Mammogram Eye Exam Pap Smear Physical Exam Social History No Yes Recreational Drugs Special Diet If yes describe: Regular Exercise If yes describe: Sexually Active □ Men □ Women □ Both GYN History OB History Age of first mensus: ( ) Menopause □ N □ Y (if yes Age: ) Total Number of Pregnancies: ( ) Regular Periods □ N □ Y Painful Periods □ N □ Y Full Term ( ) Pre Term ( ) PMS □ N □ Y – if yes describe Miscarriages ( ) Abortions ( ) Abnormal Pap: – if Yes approximate date ( ) Tubal ( ) Medical History (please check if positive) ENT GENITOURINARY SKIN Eye Problems Urinary Infections Psoriasis Sinus Problems Kidney Disease/Stones Skin Disorders Hearing Loss Erectile Dysfunction Melanoma STD CARDIOVASCULAR Urinary Incontinence Abnormal EKG MUSCULOSKELETAL PSYCH Chest Pain Arthritis/Osteo ADD/ADHD Heart Attack Arthritis/Rheumatoid Anxiety Heart Disease Gout Depression High Blood Pressure Neck/Spinal Problems Memory Loss High Cholesterol NEUROLOGICAL OCD Stroke Concussion Suicidal Thoughts/attempt Peripheral Vascular Disease Headaches PULMONARY Migraines Asthma Epilepsy/Seizures Emphysema/COPD HEMATOLOGICAL Shortness of Breath Anemia Sleep Apnea Bleeding Disorders GASTROINTESTINAL Blood Clots Acid Reflux Cancer Constipation Sickle Cell Disease Diarrhea ENDOCRINE Irritable Bowel Diabetes Gall Bladder Dise...

Terms and Exclusions. 1. The SLA explicitly does not apply to: a) other Services provided by Interconnect purchased by the Customer where no SLA is agreed. b) hardware repairs to customer equipment , unless explicitly otherwise agreed. 2. There is no Outage if the Service was unavailable due to: a) Conditions that can be attributed to the Customer, including a failure in Customer’s equipment and software installed on request of or by the Customer. In case a reported Outage is caused by such conditions, the Out of Office Hours Service Charge of €275,- per started hour per engineer is applicable. b) Maintenance and Emergency Maintenance (see 4.3 – ‘Change Management’). c) a situation where a single component, from a redundant purchased Service or option on a Service, cannot meet the required capacity (e.g. B power feed where the circuit breaker is tripping because A feed is down). d) causes outside Interconnects reasonable influence, including force majeure. This also includes the situation in which the consequences of an incident could have been minimized through the use of another Service or option on a Service, but the Customer did not purchase it at the time of the start of the incident. E.g. a DDOS attack where the option Anti-DDOS has not been purchased. e) suspension based on the Agreement.

Terms and Exclusions. I understand that the Annual Membership Fee payable to PPC Atlanta strictly covers healthcare services that are not consistently reimbursed or offered through the Medicare, Medicaid and third-party payors (health insurance) programs. As such, PPC Atlanta will not seek reimbursement for services provided as part of my Annual Membership Fee from Medicare, Medicaid, or any other third-party payer. I understand that I am solely financially responsible for payment of my Annual Membership Fee and that this fee is not reimbursable by my private insurance carrier, Medicare or Medicaid. However, the fees for my annual membership fee may be submitted to my health savings account 3 First degree family members include spouse or domestic partner, parent, sibling or child 4 If terminating from the program you must sign a HIPAA compliant request to have your records transferred to your new physician. One copy of your records will be provided to your physician at no charge. Any additional copies of your records will be charged for at then current rates. 5Failure to renew or to make quarterly payment in a timely fashion will be taken as your decision to immediately establish yourself with a new physician. ▇▇. ▇▇▇▇▇▇▇▇▇▇ will provide emergency care only for 30 days after your termination from the program. After this time ▇▇. ▇▇▇▇▇▇▇▇▇▇ will no longer be responsible for any aspect of your medical care and you should see your new physician for all medical issues. You and/or your insurance company as the case may be, will be responsible for any charges incurred for emergency care provided during this time. (HSA), medical savings account (MSA) or flexible benefits account (FBA) for reimbursement. I understand that I, or my insurance company, am responsible for all healthcare services that are traditionally covered by a health insurance program. These services exclude the services that are provided under my Annual Membership Fee. Regardless of health coverage, I understand that all co-payment, co-insurance and/or deductibles will apply as defined by my insurance policy. PPC Atlanta will bill my Payor for those services. In the event that the services are not covered by my Payor I understand that I am responsible for payment.

Terms and Exclusions. 1. The SLA explicitly does not apply to: a) other Services by Interconnect that the Customer purchases and on which no SLA is agreed. b) hardware repairs on the equipment of the Customer, unless explicitly otherwise agreed. 2. There is no Outage if the Service was unavailable due to: a) circumstances that can be attributed to the Customer, including a failure in Customer equipment and software (installed on request of or by the Customer). If it is feasible that a reported Outage is caused by such circumstances, then the Out of Office Hours Service Charge of €275,- per started hour per engineer is applicable. b) Maintenance and Emergency Maintenance (see 4.3 – ‘Change Management’). c) a situation where a single component, from a redundant purchased Service or option on a Service, cannot meet the required capacity (e.g. a B power feed where the circuit breaker is tripping because the A feed is down). d) causes that Interconnect cannot reasonably influence (including force majeure). This also includes the situation in which the consequences of an incident could have been minimized through the use of another Service or option on a Service, but the Customer did not purchase it at the time of the start of the incident.

Terms and Exclusions. 1. The SLA explicitly does not apply to: a) other Services provided by Interconnect purchased by the Customer where no SLA is agreed. b) hardware repairs to customer equipment , unless explicitly otherwise agreed. 2. There is no Outage if the Service was unavailable due to: a) Conditions that can be attributed to the Customer, including a failure in Customer’s equipment and software installed on request of or by the Customer. In case a reported Outage is caused by such conditions, the Out of Office Hours Service Charge per started hour per engineer is applicable, plus additional startingrate. (see Appendix B – Interconnect Rate Overview). b) Maintenance and Emergency Maintenance (see 4.3 – ‘Change Management’). c) a situation where a single component, from a redundant purchased Service or option on a Service, through no fault of Interconnect cannot meet the required capacity (e.g. B power feed where the circuit breaker is tripping because A feed is down). d) causes outside Interconnects reasonable influence, including force majeure. This also includes the situation in which the consequences of an incident could have been minimized through the use of another Service or option on a Service, but the Customer did not purchase it at the time of the start of the incident. E.g. a DDOS attack where the option Anti-DDOS has not been purchased. e) suspension based on the Agreement.

Terms and Exclusions i. No warranty applies to any Hardware that is: (i) returned without Rubrik’s prior written authorization pursuant to subsection 2 above; (ii) handled, transported, installed, operated, maintained, stored or used improperly, or in any manner not in accord with the Documentation, the Policy, or Rubrik's written instructions or recommendations; (iii) repaired, altered or modified other than by Rubrik or its authorized service provider; or (iv) no longer covered by the applicable Hardware Warranty due to the expiration of the applicable Term or Hardware Warranty Period. Additional charges may apply for support provided outside the applicable Warranty Period or for excluded repairs or error corrections to the extent not otherwise covered under any Hardware Warranty. ii. Warranty claims must be made within the Hardware Warranty Period. “Dead on Arrival” Hardware (“DOA Hardware”) must be reported to Rubrik within 30 calendar days of delivery of the Product. Rubrik will replace DOA Hardware by SBD as described in Section II(ii) Product. You will return the DOA Hardware to Rubrik within 14 days of receipt of the replacement unit or will pay the purchase price for the replacement unit and all associated duties, taxes, and shipment costs. iii. For Hardware Defects that require a Spare or replacement Product, you will return the applicable Spare or Hardware at your expense in accordance with Rubrik’s instructions and RMA procedures. Upon receipt of the Defective Hardware component or Product, Rubrik will ship a Spare or repaired Product to you. iv. Rubrik’s performance of the Support Services is conditioned upon all terms, conditions and pre-requisites set forth herein and in the Policy.